Organization
SUNRISE INTRACOASTAL PLASTIC SURGERY CENTER PA
Active
Other names
Sunrise Intracoastal Plastic Surgery Center PA
Organization subpart
No
Provider details
NPI number
Authorized official
JUANA DE LA GARZA (AUTHORIZED OFFICIAL)
(549) 147-5499
Entity
Organization
Contact information
Practice address
910 NE 26TH AVE, FORT LAUDERDALE, FL 33304-3607
(954) 533-8029
Mailing address
910 NE 26TH AVE, FORT LAUDERDALE, FL 33304-3607
(954) 533-8029
Taxonomy
Speciality
Code
Description
License number
State
261QA1903X
Ambulatory Surgical Clinic/Center
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
OSR105
STATE LICENSE
FL
Enumeration date
05/19/2022
Last updated
05/19/2022
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